International recommendations for outpatient palliative care and prehospital palliative emergencies - a prospective questionnaire-based investigation.

BACKGROUND: To determine the international recommendations and current practices for the treatment and prevention of palliative emergencies. The primary goal of the study was to gather information from experts on their nationally practised concepts. METHODS: One hundred and fifty self-report surveys were distributed by email to selected leading experts (palliative and emergency medical care) in Europe, North and South America, Africa, Asia, and Australia. An expert in this context was defined as an author of an article that was ranked by three reviewers as relevant to outpatient palliative and emergency medical . RESULTS: The total response rate was 61% (n = 92 experts). Survey responses were obtained from 35 different countries. The following standards in the treatment of palliative emergencies were recommended: (1) early integration of "Palliative Care Teams" (PCTs) and basic outpatient palliative care systems, (2) end-of-life discussions, (3) defined emergency medical documents, drug boxes, and "Do not attempt resuscitation" orders and (4) emergency medical training (physicians and paramedics). CONCLUSIONS: This study detected structurally and nationally differences in outpatient palliative care regarding the treatment of palliative emergencies. Accordingly, these differences should be discussed and adapted to the respective specifications of individual single countries. A single established outpatient palliative emergency medical care concept may be the basis for an overall out-of-hospital palliative care system.

Paramedics experiences and expectations concerning advance directives: a prospective, questionnaire-based, bi-centre study.

BACKGROUND: Advance directives and palliative crisis cards are means by which palliative care patients can exert their autonomy in end-of-life decisions. AIM: To examine paramedics' attitudes towards advance directives and end-of-life care. DESIGN: Questionnaire-based investigation using a self-administered survey instrument. SETTING/PARTICIPANTS: Paramedics of two cities (Hamburg and Goettingen, Germany) were included. Participants were questioned as to (1) their attitudes about advance directives, (2) their clinical experiences in connection with end-of-life situations (e.g. resuscitation), (3) their suggestions in regard to advance directives, 'Do not attempt resuscitation' orders and palliative crisis cards. RESULTS: Questionnaires were returned by 728 paramedics (response rate: 81%). The majority of paramedics (71%) had dealt with advance directives and end-of-life decisions in emergency situations. Most participants (84%) found that cardiopulmonary resuscitation in end-of-life patients is not useful and 75% stated that they would withhold cardiopulmonary resuscitation in the case of legal possibility. Participants also mentioned that more extensive discussion of legal aspects concerning advance directives should be included in paramedic training curricula. They suggested that palliative crisis cards should be integrated into end-of-life care. CONCLUSIONS: Decision making in prehospital end-of-life care is a challenge for all paramedics. The present investigation demonstrates that a dialogue bridging emergency medical and palliative care issues is necessary. The paramedics indicated that improved guidelines on end-of-life decisions and the termination of cardiopulmonary resuscitation in palliative care patients may be essential. Participants do not feel adequately trained in end-of-life care and the content of advance directives. Other recent studies have also demonstrated that there is a need for training curricula in end-of-life care for paramedics.

Prehospital emergency treatment of palliative care patients with cardiac arrest: a retrolective investigation.

BACKGROUND: Today, prehospital emergency medical teams (EMTs) are confronted with emergent situations of cardiac arrest in palliative care patients. However, little is known about the out-of-hospital approach in this situation and the long-term survival rate of this specific patient type. The aim of the present investigation was to provide information about the strategic and therapeutic approach employed by EMTs in outpatient palliative care patients in cardiac arrest. METHODS: During a period of 2 years, we retrolectively analysed emergency medical calls with regard to palliative care emergency situations dealing with cardiac arrest. We evaluated the numbers of patients who were resuscitated, the prevalence of an advance directive or other end-of-life protocol, the first responder on cardiac arrest, the return of spontaneous circulation (ROSC) and the survival rate. RESULTS: Eighty-eight palliative care patients in cardiac arrest were analysed. In 19 patients (22%), no resuscitation was started. Paramedics and prehospital emergency physicians began resuscitation in 61 cases (69%) and in 8 cases (9%), respectively. A total of 10 patients (11%) showed a ROSC; none survived after 48 h. Advance directives were available in 43% of cases. The start of resuscitation was independent of the presence of an advance directive or other end-of-life protocol. CONCLUSIONS: Strategic and therapeutic approaches in outpatient palliative care patients with cardiac arrest differ depending on medical qualification. Although many of these patients do not wish to be resuscitated, resuscitation was started independent of the presence of advance directive. To reduce legal insecurity and to avoid resuscitation and a possible lengthening of the dying process, advance directives and/or "Do not attempt resuscitation" orders should be more readily available and should be adhered to more closely.

Quality of out-of-hospital palliative emergency care depends on the expertise of the emergency medical team--a prospective multi-centre analysis.

BACKGROUND: The number of palliative care patients who live at home and have non-curable life-threatening diseases is increasing. This is largely a result of modern palliative care techniques (e.g. specialised out-of-hospital palliative medical care services), changes in healthcare policy and the availability of home care services. Accordingly, pre-hospital emergency physicians today are more likely to be involved in out-of-hospital emergency treatment of palliative care patients with advanced disease. METHODS: In a prospective multi-centre study, we analysed all palliative emergency care calls during a 24-month period across four emergency services in Germany. Participating pre-hospital emergency physicians were rated according to their expertise in emergency and palliative care as follows--group 1: pre-hospital emergency physicians with high experience in emergency and palliative medical care, group 2: pre-hospital emergency physicians with high experience in emergency medical care but less experience in palliative medical care and group 3: pre-hospital emergency physicians with low experience in palliative and emergency medical care. RESULTS: During the period of interest, the centres received 361 emergency calls requiring a response to palliative care patients (2.8% of all 12,996 emergency calls). Ten percent of all patients were treated by group 1; 42% were treated by group 2 and 47% were treated by group 3. There was a statistically significant difference in the treatment of palliative care patients (e.g. transfer to hospital, symptom control, end-of-life decision) as a result of the level of expertise of the investigated pre-hospital emergency physicians (p< 0.01). CONCLUSIONS: In Germany, out-of-hospital emergency medical treatment of palliative care patients depends on the expertise in palliative medical care of the pre-hospital emergency physicians who respond to the call. In our investigation, best out-of-hospital palliative medical care was given by pre-hospital emergency physicians who had significant expertise in palliative and emergency medical care. Our results suggest that it may be necessary to take the core principles of palliative care into consideration when conducting out-of-hospital emergency medical treatment of palliative care patients.

Emergency calls and need for emergency care in patients looked after by a palliative care team: Retrospective interview study with bereaved relatives.

BACKGROUND: During the last stage of life, palliative care patients often experience episodes of respiratory distress, bleeding, pain or seizures. In such situations, caregivers may call emergency medical services leading to unwanted hospital admissions. The study aims to show the influence of our palliative care team to reducing emergency calls by cancer patients or their relatives during the last six month of life. METHODS: Fifty relatives of deceased patients who had been attended by our palliative care team were randomly selected. Data was obtained retrospectively during a structured interview. In addition to demographic data, the number of emergency calls made during the final six months of the patient's life, the reason for the call and the mental compound score (MCS-12) of the caregivers was registered. RESULTS: Forty-six relatives agreed to the interview. Emergency calls were placed for 18 patients (39%) during the final six months of their lives. There were a total of 23 emergency calls. In 16 cases (70%) the patient was admitted to the hospital. Twenty-one (91%) of the calls were made before patients had been enrolled to receive palliative care from the team, and two (9%) were made afterwards. The mean mental compound score of the caregivers at the time of the interview was 41 (range 28-57). There was a lack of correlation between MCS-12 and number of emergency calls. CONCLUSION: Emergency calls were more likely to occur if the patients were not being attended by our palliative care team. Because of the lack of correlation between MCS-12 and the number of emergency calls, the MCS-12 cannot indicate that acutely stressful situations triggered the calls. However, we conclude that special palliative care programs can reduce psychosocial strain in family caregivers. Therefore, the number of emergency calls may be reduced and this fact allows more palliative patients to die at home.

Influence of isoflurane on the diastolic pressure-flow relationship and critical occlusion pressure during arterial CABG surgery: a randomized controlled trial.

The effects of isoflurane on the determinants of blood flow during Coronary Artery Bypass Graft (CABG) surgery are not completely understood. This study characterized the influence of isoflurane on the diastolic Pressure-Flow (P-F) relationship and Critical Occlusion Pressure (COP) during CABG surgery. Twenty patients undergoing CABG surgery were studied. Patients were assigned to an isoflurane or control group. Hemodynamic and flow measurements during CABG surgery were performed twice (15 minutes after the discontinuation of extracorporeal circulation (T15) and again 15 minutes later (T30)). The zero flow pressure intercept (a measure of COP) was extrapolated from a linear regression analysis of the instantaneous diastolic P-F relationship. In the isoflurane group, the application of isoflurane significantly increased the slope of the diastolic P-F relationship by 215% indicating a mean reduction of Coronary Vascular Resistance (CVR) by 46%. Simultaneously, the Mean Diastolic Aortic Pressure (MDAP) decreased by 19% mainly due to a decrease in the systemic vascular resistance index by 21%. The COP, cardiac index, heart rate, Left Ventricular End-Diastolic Pressure (LVEDP) and Coronary Sinus Pressure (CSP) did not change significantly. In the control group, the parameters remained unchanged. In both groups, COP significantly exceeded the CSP and LVEDP at both time points. We conclude that short-term application of isoflurane at a sedative concentration markedly increases the slope of the instantaneous diastolic P-F relationship during CABG surgery implying a distinct decrease with CVR in patients undergoing CABG surgery.

Post-mortal bereavement of family caregivers in Germany: a prospective interview-based investigation.

BACKGROUND: Care aspects of outpatient palliative-care teams involve the medical, psychological, and spiritual needs of patients and their caregivers. The objective of our study was to examine the post-mortal bereavement of family caregivers. METHODS: The investigation was based on interviews with 50 family caregivers of 50 palliative-care patients assessed by a palliative-care team. Each caregiver was interviewed using interview sheets (mixed method designs) in accordance with three groups of validated criteria for complicated grief: Prigerson, Horowitz, and ICD-10. RESULTS: Forty-six family caregivers of terminally ill patients participated in the study. Complicated grief existed in up to 30% of the caregivers, based on the three sets of criteria. There was no significant difference (P > 0.05) among the three groups and no significant differences were found (P > 0.05) in relation to age, sex, psychosocial distress, primary cancer disease, and duration of illness or quality of care. Overall, 97% of the care-giving relatives were satisfied with the help given by the palliative-care team. CONCLUSION: The results of the study suggest that care from a specialized palliative-care team providing psychological and social support may reduce the risk of complicated grief. Careful exploration of possible risk factors for complicated grief is important for optimal care. Our study shows that healthcare providers play an important role in helping family caregivers to manage the multiple burdens and the grieving reaction. Family-focused grief therapy may prevent complicated grieving reactions.

Out-of-hospital opioid therapy of palliative care patients with "acute dyspnoea": a retrospective multicenter investigation.

BACKGROUND: Prehospital emergency physicians (EP) are often confronted with the acute care of palliative care patients. Dyspnoea is a frequent acute symptom and its causes often differ from the generally known emergency medical causes. Till now, there have been no relevant concepts for emergency care of palliative care patients for their specific symptoms. METHODS: Over a 24-month period, the authors retrospectively investigated all out-of-hospital emergency medical services for palliative care patients with acute dyspnoea at four emergency physician support points. The evaluation of these services was followed retrospectively on the basis of the therapy carried out by the EP (Group 1: therapy with morphine and oxygen; Group 2: therapy with morphine, bronchodilator effective drugs and oxygen; Group 3: therapy with bronchodilator effective drugs and oxygen; Group 4: therapy with oxygen; Group 5: no medical treatment). Moreover, EPs were interviewed about their actions and their uncertainties in the treatment of palliative care patients. RESULTS: The diagnosis of acute dyspnoea in palliative care patients occurred 121 times (116 patients were integrated in the present investigation) within the defined period. In total, 116 patients were included (Group 1: 21, Group 2: 29, Group 3: 31, Group 4: 28, and Group 5: 7). Dyspnoea was satisfactorily treated in 41 percent of the patients (Group 1: 67 percent, Group 2: 52 percent, Group 3: 22 percent, Group 4: 18 percent, and Group 5: 71 percent). Most EPs (70 percent) revealed uncertainties in emergency medical therapy for patients at the end of life. CONCLUSIONS: The current investigation showed a significant relief of acute dyspnoea when using opioids, in contrast with the established out-of-hospital emergency medical therapy for acute dyspnoea. Therefore, opioids should be recommended for emergency medical therapy of dyspnoea in palliative care patients. Clinical studies that recommend the use of effective opioids for the treatment of dyspnoea in palliative care patients are supported by the current retrospective study. Most EPs felt uncertain in the treatment of palliative care patients. Therefore, advanced training in palliative care medicine and end-of-life care should be integrated into emergency medical training.

Myocardial ischemia with left ventricular outflow obstruction.

We report an unusual case of a 32-year old man who was treated for a hypertrophic obstructive cardiomyopathy (HOCM) with a DDD pacing with short AV delay reduction in the past. Without prior notice the patient developed ventricular fibrillation and an invasive cardiac diagnostic was performed, which revealed a myocardial bridging around of the left anterior descending artery (LAD). We suspected ischemia that could be either related to LAD artery compression or perfusion abnormalities due to AV delay reduction with related to diastolic dysfunction.

[Emergency outpatient palliative care in acute situations by paramedics]. / Betreuung von Palliativpatienten in Akutsituationen durch Rettungsassistenten.

BACKGROUND: In recent years outpatient palliative care, even for patients in an advanced state of their disease, has gained importance. Therefore, also paramedics are more often confronted with palliative emergencies, advance directives, and ethical end-of-life issues. Presently in emergency medicine there is undoubtedly a lack of education on palliative medicine and ethical questions for paramedics. METHODS: In a period of six months we questioned 250 paramedics from two German regions (Göttingen and Braunschweig) about their experiences in palliative medicine, palliative emergencies and about their knowledge of advance directives. For these key questions we drew up a specific questionnaire. RESULTS: The response rate in the set period of time amounted to 64.8% (n = 162). Most of the interviewed paramedics (91.4%, n = 148) had been confronted with palliative emergency situations on duty. 47.6% felt uncertain about the correct psychosocial care of the patients. 84% of the paramedics were insecure concerning their knowledge about advance directives. 72.8% had already taken care of patients with advance directives. These advance directives had influenced their therapy decision in 42.8%. CONCLUSION: The emergency treatment of palliative patients can present a particular challenge to paramedics. Most of the interviewed paramedics felt insecure both about the social care and the assessment of legal issues in dealing with advance directives and decisions at the end of life. Therefore emergency medical training apparently needs to be improved in these fields. Further information and training are necessary to guarantee adequate patient-oriented care of palliative patients und their relatives also in emergency situations.